Scholarly article on topic 'Reversal of Profound Neuromuscular Blockade with Sugammadex after Failure of Rapid Sequence Endotracheal Intubation: a Case Report'

Reversal of Profound Neuromuscular Blockade with Sugammadex after Failure of Rapid Sequence Endotracheal Intubation: a Case Report Academic research paper on "Clinical medicine"

CC BY-NC-ND
0
0
Share paper
Academic journal
Brazilian Journal of Anesthesiology
OECD Field of science
Keywords
{"Intraoperative Complications" / "Intubation / Intratracheal" / "Cyclodextrin / Sugammadex" / "BLOQUEADOR MUSCULAR / Rocurônio" / "COMPLICAÇÕES / Intubação Traqueal" / "BLOQUEADOR MUSCULAR / Rocuronio" / "COMPLICACIONES / Intubación Traquea"}

Abstract of research paper on Clinical medicine, author of scientific article — Fabiano Timbó Barbosa, Rafael Martins da Cunha

Summary Barbosa FT, Cunha RM – Reversal of Profound Neuromuscular Blockade with Sugammadex after Failure of Rapid Sequence Endotracheal Intubation: a Case Report. Background and objectives Sugammadex is a reversal agent that acts as a selective antagonist of neuromuscular blockade induced by rocuronium and vecuronium. This is a case report of an elderly female patient who had sugammadex just after rocuronium induction. Case report An 88-year-old female patient, 34kg, presented a femoral fracture and had to undergo general anesthesia after spinal anesthesia failure. Induction was performed with propofol 1.5mg.kg-1, rocuronium 1.2mg.kg-1, fentanyl 100mcg, and lidocaine 2mg.kg-1. There was no success in either tracheal intubation or laryngeal mask positioning maneuvers. The use of sugammadex at a dose of 16mg.kg-1 was required and respiratory function returned to normal. Conclusion Literature recommends sugammadex at a dose of 16mg.kg-1 for patients with profound blockade. It was used in our patient with rapid and effective reversal of neuromuscular blockade allowing the patient to undergo another procedure to ensure the airway patency without clinical impairment of her general condition.

Academic research paper on topic "Reversal of Profound Neuromuscular Blockade with Sugammadex after Failure of Rapid Sequence Endotracheal Intubation: a Case Report"

Rev Bras Anestesio! 2012; 62: 2: 281-284

CLINICAL INFORMATION

Reversal of Profound Neuromuscular Blockade with Sugammadex after Failure of Rapid Sequence Endotracheal Intubation: a Case Report

Fabiano Timbó Barbosa 1, Rafael Martins da Cunha 2

Summary: Barbosa FT, Cunha RM - Reversal of Profound Neuromuscular Blockade with Sugammadex after Failure of Rapid Sequence Endotracheal Intubation: a Case Report.

Background and objectives: Sugammadex is a reversal agent that acts as a selective antagonist of neuromuscular blockade induced by rocu-ronium and vecuronium. This is a case report of an elderly female patient who had sugammadex just after rocuronium induction.

Case report: An 88-year-old female patient, 34 kg, presented a femoral fracture and had to undergo general anesthesia after spinal anesthesia failure. Induction was performed with propofol 1.5 mg.kg-1, rocuronium 1.2 mg.kg-1, fentanyl 100 mcg, and lidocaine 2 mg.kg-1. There was no success in either tracheal intubation or laryngeal mask positioning maneuvers. The use of sugammadex at a dose of 16 mg.kg-1 was required and respiratory function returned to normal.

Conclusion: Literature recommends sugammadex at a dose of 16 mg.kg-1 for patients with profound blockade. It was used in our patient with rapid and effective reversal of neuromuscular blockade allowing the patient to undergo another procedure to ensure the airway patency without clinical impairment of her general condition.

Keywords: Intraoperative Complications; Intubation, Intratracheal; Cyclodextrin, Sugammadex.

©2012 Elsevier Editora Ltda. All rights reserved.

INTRODUCTION

Sugammadex is a chemically modified gamma-cyclodextrin that acts as a selective antagonist of neuromuscular blockade induced by rocuronium and vecuronium 1. Rocuronium has proved to be a reasonable alternative to provide a rapid sequence induction without the occurrence of some events observed in patients when using succinylcholine, such as hy-perkalemia, masseter muscle rigidity, reported onset of malignant hyperthermia (in some cases after its usage). Sugammadex has been used to provide the reversal of various doses of rocuronium (0.6, 1.0, and 1.2 mg.kg-1) 2.

The aim of this report is to describe a case in which sugam-madex was used to reverse muscle relaxation immediately after rocuronium induction in an elderly patient, following unsuccessful tracheal intubation maneuvers.

Received from Hospital Unimed - Maceió, Brazil.

1. Master of Science; Professor, Universidade Federal de Alagoas

2. Diploma in teaching at higher education; Anesthesiologist, Hospital Unimed, Maceió

Submitted on November 17, 2010 Approved on June 19, 2011

Correspondence to:

Dr. Fabiano Timbó Barbosa

Rua Comendador Palmeira, 113, apto 202

57051150 - Farol, Maceió, AL, Brazil

E-mail: fabianotimbo@yahoo.com.br

Revista Brasileira de Anestesiología Vo!. 62, № 2, March-April, 2012

CASE REPORT

RBQC, aged 88 years and 9 months, 34 kg, female, presented with femoral neck fracture 8 hours before the procedure, ASA II, skinny, with a history of lumbar spine ankylosis and no additional comorbidities. In the operating room, the patient was monitored with ECG, neuromuscular junction monitor, oximetry, bispectral index, and noninvasive arterial pressure. After being monitored she was placed in a sitting position for spinal anesthesia; the procedure was not successful due to a marked degree of scolio-sis and inability to identify the subarachnoid space.

General anesthesia was performed with induction of propofol 1.5 mg.kg-1, rocuronium 1.2 mg.kg-1, fentanyl 100 mcg, and lidocaine 2 mg.kg-1. Tracheal intubation was attempted three times unsuccessfully; the laryngeal mask did not adapt to the patient due to her protruding teeth, and they were unable to ventilate with a face mask. At this point, the use of sugammadex at a dose of 540 mg (16 mg.kg-1) was selected, obtaining rapid reversal of respiratory activity.

Patient had no cardiovascular changes along or after the intubation procedures and reversal of rocuronium. The monitor of neuromuscular blockade was installed after the reversal and the monitored TOF value reached 0.95. The operation proceeded with the surgical airway technique under local anesthesia. The patient was discharged after three days without sequelae.

DISCUSSION

Acetylcholinesterase antagonists do not allow a rapid reversal of profound neuromuscular blockade, while sugammadex has the potential for this type of reversal with the return of

muscle activity occurring in less than 2 minutes compared to neostigmine 3. The sugammadex-rocuronium interaction reduces the amount of free rocuronium plasma concentration, decreasing the affinity of the rocuronium still connected to the acetylcholine receptor, which in turn increases the amount of this muscle relaxant in plasma derived from stocks of relaxant linked to the receptor, and also enables the connection of sugammadex plasma free molecules with the rocuronium that has lost its connection with the nicotinic receptor, which eventually returns to the plasma 4. The mean plasma clearance in man of 70 kg is 120 mL.min-1, distribution volume is 18 L, and half-life is 100 minutes 5. Profound neuromuscular blockade should be reversed with 4 mg.kg-1 and moderate blocking with a dose of 2 mg.kg-1 5.

Rocuronium at a dose of 1.0 mg.kg-1 is recommended for rapid sequence intubation in conditions similar to succinylcho-line and within 60 seconds 2. In this case report the recommendation was followed. However, an event of impossible intubation was diagnosed, as it was not possible to intubate or ventilate the patient. Sugammadex at a dose of 16 mg.kg-1, immediately after the use of rocuronium, was recently indicated as effective to reverse profound neuromuscular blockade 56. This same dose was used in the patient with clinically effective reversal. Puhringer et al. 7 conducted a study using a dose of 16 mg.kg-1 and reported that the median time for reversal of neuromuscular blockade was 1.9 minutes.

Neostigmine presents longer time for reversal (> 66.2 min.) than sugammadex which lasts for only 4.5 minutes 3. Neostigmine may also fail to reverse profound neuromuscular blockade and may not provide good conditions to extubate patients 8. There was no evidence of the need of neostigmine in this case report.

Recurarization after sugammadex administration has been reported in cases which doses were lower than 2.0 mg.kg-1 9-10. As the mechanism of action is different from acetylcholinest-erase inhibitors, the drug has low potential to generate arrhythmias 5. Doses as high as 40 mg.kg-1 did not induce arrhythmias 5.

In Brazilian literature there are no researches involving the use of sugammadex in trauma centers; therefore, studies are necessary to elucidate the optimal dose in multisystem trauma patients.

CONCLUSION

Literature recommends sugammadex at a dose of 16 mg.kg-1 for patients with profound neuromuscular blockade. It was used in this case report with rapid and effective reversal of blockade, allowing the patient to undergo another procedure to ensure airway patency without clinical impairment of her general condition.

Revista Brasileira de Anestesiologia Vol. 62, № 2, March-April, 2012

Rev Bras Anestesio! 2012; 62: 2: 281-284

INFORMAQÓES CLÍNICAS

Reversáo de Bloqueio Muscular Profundo com Sugammadex Após Falha de Intubagáo Traqueal em Sequencia Rápida: Relato de Caso

Fabiano Timbó Barbosa 1, Rafael Martins da Cunha 2

Resumo: Barbosa FT, Cunha RM - Reversáo de Bloqueio Muscular Profundo com Sugammadex Após Falha de Intubagáo Traquea! em Sequencia Rápida: Relato de Caso.

Justificativa e objetivos: O sugammadex é um agente reversor superseletivo do bloqueio neuromuscular utilizado para a reversáo de rocuronio e vecuronio. Este relato descreve um caso clínico em que o sugammadex foi utilizado em paciente idosa imediatamente após uso de rocuronio.

Relato do caso: Paciente do sexo feminino, 88 anos, 34 kg, com fratura de fémur foi submetida á anestesia geral após tentativa falha de raquia-nestesia. Optou-se por indugáo anestésica com propofol 1,5 mg.kg-1, rocuronio 1,2 mg.kg-1, fentanil 100 mcg e lidocaína 2 mg.kg-1. Náo houve sucesso nas manobras para intubagáo traqueal nem no posicionamento da máscara laríngea. Optou-se pelo uso de sugammadex na dose de 16 mg.kg-1 com retorno da fungáo respiratória.

Conclusoes: A dose recomendada pela literatura para o sugammadex em pacientes com bloqueio profundo, 16 mg.kg-1, foi utilizada nesta paciente com reversáo rápida e eficaz do bloqueio neuromuscular permitindo que a paciente fosse submetida a outro procedimento para garantir a perviedade das vias aéreas sem comprometimento clínico de seu estado geral.

Unitermos: BLOQUEADOR MUSCULAR, Rocuronio; COMPLICAQÓES, Intubagáo Traqueal.

©2012 Elsevier Editora Ltda. Todos os direitos reservados.

INTRODUQÁO

O sugammadex é uma gama-ciclodextrina quimicamente modificada que atua como antagonista seletivo de bloqueio neuromuscular com rocuronio e vecuronio 1. O rocuronio tem se mostrado uma alternativa razoável para providenciar uma indugáo em sequencia rápida, sem alguns eventos presentes no paciente quando se utiliza a succinilcolina, como hiper-potassemia, rigidez de masseter e relato de surgimento de hipertermia maligna (em alguns casos após o seu uso). O fármaco vem sendo utilizado para providenciar reversáo de várias doses de rocuronio (0,6; 1,0; e 1,2 mg.kg-1) 2.

O objetivo deste relato foi descrever um caso de utilizagáo de sugammadex como reversor de bloqueio de relaxamento muscular imediatamente após uso de rocuronio em paciente idosa com insucesso nas manobras de intubagáo traqueal.

Recebido pelo Hospital Unimed - Maceió, Brasil.

1. Mestre em Ciencias; Professor da Universidade Federal de Alagoas

2. Especialista em docencia para o ensino superior, Anestesiologista do Hospital Unimed - Maceió

Submetido em 17 de novembro de 2010. Aprovado para publicagao em 19 de junho de 2011.

Correspondencia para:

Dr. Fabiano Timbó Barbosa

Rua Comendador Palmeira, 113, apto 202

57051150 - Maceió, AL, Brasil E-mail: fabianotimbo@yahoo.com.br

RELATO DE CASO

RBQC, 88 anos e 9 meses, peso 34 kg, sexo feminino, fratura de colo de femur oito horas antes do procedimento, ASA II, longilínea, com passado de anquilose de vértebras lombares e sem outras comorbidades. Ao entrar no centro cirúrgico, foi monitorada com eletrocardioscopia, monitor da jungáo neuro-muscular, oximetria, índice Bispectral e pressáo arterial náo invasiva. Após monitoragáo, a paciente foi sentada para ra-quianestesia, procedimento que náo foi bem sucedido devido a acentuado grau de escoliose e impossibilidade de identifi-cagáo do espago subaracnoideo.

Optou-se por anestesia geral com a indugáo realizada com propofol 1,5 mg.kg-1, rocuronio 1,2 mg.kg-1, fentanil 100 mcg e lidocaína 2 mg.kg-1. A intubagáo traqueal foi tentada por tres vezes sem sucesso; a máscara laríngea náo se adaptou a paciente devido a protusáo dentária e náo se conseguiu ventilar com a máscara facial. Neste momento, optou-se por sugammadex na dose de 540 mg (16 mg.kg-1) com reversáo rápida da atividade respiratória.

Paciente náo apresentou alteragoes cardiovasculares durante e após o procedimento de intubagáo traqueal e reversáo do rocuronio. O monitor de bloqueio neuromuscular foi instalado após a reversáo e o TOF monitorado demonstrou valor de 0,95. Optou-se entáo por via aérea cirúrgica sob anestesia local para seguimento do procedimento cirúrgico. A paciente recebeu alta hospitalar após tres dias de interna-gáo sem sequelas.

Revista Brasileira de Anestesiologia Vol. 62, № 2, Margo-Abril, 2012

DISCUSSÄO

Os antagonistas da acetilcolinesterase nao permitem uma reversao rápida de bloqueio neuromuscular profundo e o sugammadex possui potencial para este tipo de reversao ocor-rendo retorno da atividade muscular em tempo menor que dois minutos na comparaçao com a neostigmina 3. A intera-çao rocurônio-sugammadex reduz a quantidade de rocurônio livre no plasma, diminuindo a afinidade do rocurônio que ainda está ligado ao receptor da acetilcolina que, por sua vez, aumenta a quantidade deste relaxante muscular no plasma proveniente dos estoques de relaxante que estavam ligados ao receptor, e também possibilita a ligaçao de moléculas de sugammadex livres no plasma com o rocurônio que perdeu sua ligaçao com o receptor nicotínico, que, por fim, retorna ao plasma 4. A média do clearance plasmático em homem de 70 kg é de 120 mL.min-1, o volume de distribuiçao é de 18 L e a meia-vida de eliminaçao é de 100 minutos 5. O bloqueio neuromuscular profundo deve ser revertido com 4 mg.kg-1 e o bloqueio moderado com a dose de 2 mg.kg-1 5.

A dose de rocurônio de 1,0 mg.kg-1 é recomendada para intubaçao em sequência rápida em condiçôes semelhantes à succinilcolia e em um prazo de 60 segundos 2. No caso em questao, esta recomendaçao foi seguida. Entretanto, diag-nosticou-se um caso de intubaçao impossível, uma vez que nao se conseguiu intubar nem ventilar a paciente em questao. A dose de sugammadex de 16 mg.kg-1 imediatamente após a utilizaçao do rocurônio foi recentemente indicada para a reversao de bloqueio muscular profundo como sendo efetiva 56. Esta dose foi utilizada na paciente em questao com reversao clinica efetiva. Pühringer e col. 7 realizaram estudo com dose de 16 mg.kg-1 relatando que o tempo médio para reversao do bloqueio foi de 1,9 minutos.

A neostigmina apresenta tempo para reversao maior que o sugammadex, pode alcançar até 66,2 minutos quando comparada com o sugammadex, por exemplo, que se estende apenas por 4,5 minutos 3. A neostigmina pode também falhar na reversao de bloqueios neuromusculares profundos e nao permitir boas condiçôes para extubaçao dos pacientes 8. A neostigmina nao foi utilizada em virtude da inexistência de evi-dências demonstrando resultados favoráveis nesta situaçao.

A ocorrência de recurarizaçao após a administraçao de sugammadex foi relatada em casos cujas doses utilizadas fo-ram menores que 2,0 mg.kg-1 910. Em virtude do mecanismo de açao ser diferente dos inibidores da acetilcolinesterase, o fármaco possui baixo potencial para gerar arritmias 5. Doses tao altas quanto 40 mg.kg-1 nao induziram arritmias graves 5.

A literatura brasileira ainda nao abordou pesquisas en-volvendo o uso do sugammadex no ambiente dos hospitais de trauma sendo necessários novos estudos para elucidar a dose ideal em pacientes traumatizados multissistêmicos.

CONCLUSÄO

A dose recomendada pela literatura para o sugammadex em pacientes com bloqueio profundo, 16 mg.kg-1, foi utilizada nesta paciente com reversao rápida e eficaz do bloqueio neu-

romuscular permitindo que a paciente fosse submetida a ou-tro procedimento para garantir a perviedade das vias aéreas sem comprometimento clínico de seu estado geral.

REFERENCIAS / REFERENCES

01. Bom A, Bradley M, Cameron K et al. - A novel concept of reversing neuromuscular block: chemical encapsulation of rocuronium bromide by a cyclodextrin-based synthetic host. Angew Chem Int Ed Engl, 2002;41:266-270.

02. Pühringer FK, Kristen P, Rex C - Sugammadex reversal of rocuro-nium- induced neuromuscular block in Caesarean section patients: a series of seven cases. Br J Anaesth, 2010;105:657-660.

03. Lemmens HJ, El- Orbany MI, Berry J, et al - Reversal of profound vecuronium - induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmine. BMC Anesthesiol, 2010;10:15.

04. Epemolu O, Bom A, Hope F et al. - Reversal of neuromuscular block and simultaneous increase in plasma rocuronium concentration after the intravenous infusion of the novel reversal agent Org 25969. Anesthesiology, 2003;99:632-637.

05. Rex C, Bergner UA, Pühringer FK - Sugammadex: a selective relaxant- binding agent providing rapid reversal. Curr Opin Anaesthesiol, 2010;23:461-465.

06. Lee C, Jahr JS, Candiotti KA, Warriner et al - Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from suc-cinylcholine. Anesthesiology, 2009;110:1020-1025.

07. Pühringer FK, Rex C, Sielenkämper AW et al. - Reversel of profound, high-dose rocuronium-induced neuromuscular blockade by sugam-madex at two different time points. Anesthesiology, 2008;109:188-197.

08. Kopman AF, Zank LM, Ng J et al. - Antagonism of cisatracurium and rocuronium block at a tactile train of four count of two: should quantitative assessment of neuromuscular function be mandatory? Anesth Analg, 2004;98:102-106.

09. Khuenl-Brady KS, Wattwil M, Vanacker BF et al. - Sugammadex provides faster reversal of vecuronium-induced neuromuscular blockade compared with neostigmine: a multicenter, randomized, controlled trial. Anesth Analg, 2010;110:64-73.

10. Eleveld DJ, Kuizenga K, Proost JH et al. - A temporary decrease in twitch response during reversal of rocuronium-induced muscle relaxation with a small dose of sugammadex. Anesth Analg, 2007;104:582-584.

Resumen: Barbosa FT, Cunha RM - Reversión del Bloqueo Muscular Profundo con Sugamadex Posteriormente al Fallo de Entubación Traqueal en Secuencia Rápida: Relato de Caso.

Justificativas y objetivos: El sugamadex es un agente reversor su-perselectivo del bloqueo neuromuscular utilizado para la reversión de rocuronio y vecuronio. Este relato describe un caso clínico en que el sugamadex fue utilizado en una paciente anciana inmediatamente después del uso del rocuronio.

Relato del caso: Paciente del sexo femenino, 88 años, 34 kg, con fractura del fémur, que fue sometida a la anestesia general después del intento de la raquianestesia. Se optó por la inducción anestésica con el propofol 1,5 mg.kg-1, rocuronio 1,2 mg.kg-1, fentanil 100 mcg y lidocaina 2 mg.kg-1. No hubo éxito en las maniobras para la entubaci-ón traqueal ni en el posicionamiento de la máscara laríngea. Se optó por el uso de sugamadex en una dosis de 16 mg.kg-1 con retorno de la función respiratoria.

Conclusiones: La dosis recomendada por la literatura para el sugamadex en pacientes con bloqueo profundo, 16 mg.kg-1, fue utilizada en esta paciente con una reversión rápida y eficaz del bloqueo neuro-muscular, permitiendo que la paciente fuese sometida a otro procedimiento para garantizar el paso por las vías aéreas sin el compromiso clínico de su estado general.

Descriptores: BLOQUEADOR MUSCULAR, Rocuronio; COMPLICACIONES, Intubación Traqueal.

Revista Brasileira de Anestesiologia Vol. 62, № 2, Margo-Abril, 2012